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Nurs 311 Health Assessment Exam 1 LATEST
2024 EXAM COMPLETE QUESTION AND
ANSWER SCORE A (SUMMER-FALL)
- incorporation of impact of external and interpersonal environment on one's mind and body holistic model `
- what has the greatest influence on health status poverty
- broader term that encompasses something larger than one's own existence with a belief in transcendence spirituality
- refers to an organized system of beliefs as a shared experience that can assist in meeting one's individual spiritual needs religion
- do religion and spirituality have to exist simultaneously no
- expectations, manifestations and management of pain are all embedded in a cultural context
- a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person pain
- identified as the most valued response to pain by health care professionals silent suffering
- what are the four aspects of becoming a culturally competent nurse culturally sensitive, appropriate, competent, and cultural care
- caregivers possess basic knowledge and understanding culturally sensitive
- caregivers apply knowledge to improve health outcomes culturally appropriate
- caregivers apply a universal concept of understanding to all contextual aspects of care culturally competent
body language helps to provide cues which may be correlated with truer feelings, recognize importance of unconscious messages non verbal communcation external factors of communication include ensure privacy, avoid interruptions, physical environment, dress, note taking the federal government mandates this so as to improve quality and safety electronic health record (ehr) collect subjective data to combine with objective data from physical exam and lab studies to form the database, provides complete picture of patients past and present health status, screening tool for detection of abnormalities, health history what is the health history sequence biographic data, source of history, reason for seeking care, present health or history of present illness, past health, family history, review of systems, functional assessment including activity of daily living name, address, phone number, age, birth date, birthplace, gender, race and ethnic origin, occupation and primary language are all in what category of the health history sequence biographic data
3 parts of source of history for health history sequence record, judge, note subjective sensation person feels from disorder documented in quotes symptom objective abnormality that can be detected on physical examination or in laboratory reports sign eight critical characteristics (present health or history of present illness) location, character (quality), quantity (severity), timing, setting, aggravating or relieving factors, associated factors and patients perception what is the purpose of review of systems evaluate past and present state of each body system, assess that all pertinent data relative to each body system have been notes, evaluate health promotion practices organized manner proceeding in a logical sequence cephalocaudal approach
best for determining temperature because skin here is thinner than on palms dorsa of hands and fingers best for vibration base of fingers or ulnar surface of hand study of the whole person general survey covers general health state and any obvious physical characteristics, provides an overall impression, includes objective parameters that apply to the whole body, includes areas of physical appearance, body structure, mobility and behavior general survey characteristics Age, sex, level of consciousness, skin color, facial features, and overall appearance are all examples of objective data stature, nutrition, symmetry, posture position, posture and position objective data aspects of gait
foots placement and range of motion short term and self limiting, often follows a predictable trajectory, and dissipates after an injury heals acute pain diagnosed when pain continues for 6 months or longer, can be divided into malignant and nonmalignant chronic pain transient spike in pain level, moderate to severe in intensity, in an otherwise controlled pain syndrome breakthrough pain gold standard of pain assessment self report what are the two main pain pathways nociceptive and neuropathic felt at particular site, but originates from another location referred pain
for a limited or short term problem, more targeted, concerns mainly one problem, or one body system, used in all settings focused assessment this type of pain scale asks the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and 10 indicating the worst pain every experienced numeric rating scale best for high pitched sounds- breath, bowl and normal heart sounds diaphragm deep, hollow cuplike shape. best for soft, low pitched sounds such as heart sounds or murmurs bell hypoventilation, hypoxia, decreased cough, and atelectasis are all acute pain responses related to which physiologic system pulmonary fear anxiety and fatigue are acute pain responses associated with which system cns
what does oldcart stand for (focused assessment, symptom assessment) onset, location, duration, characteristic symptoms, associated manifestations, relieving factors, treatment difficult or labored breathing dyspnea what is the pitch of bronchial breath sounds high what is the amplitude of bronchial breath sounds loud duration of bronchial breath sounds inspiration < expiration quality of bronchial breath sounds harsh, hollow tubular normal location of bronchial sounds trachea and larynx
inspiration > expiration qualitiy of vesicular breath sounds rustling over peripheral lung fields where air flows through smaller bronchioles and alveoli vesicular breath sound location rapid, shallow breathing, increased rate >24/minute tachypnea slow breathing, decreased but regular rate bradypnea a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. breathing periods last 30 to 45 sec with periods of apnea cheyne stokes anterior thoracic landmarks include suprasternal notch, sternum, sternal angle, costal angle
posterior thoracic landmarks include vertebra prominens, spinous processes, inferior border of the scapula, twelfth rib middle section of the thoracic cavity containing the esophagus, trachea, heart, great vessels mediastinum which lung is shorter right how many lobes does the right lung have three how many lobes does the left lung have two crosses the 5th rib in the midaxillary line and terminates at the 6th rib in the midclavicular line oblique fissure divides the right upper and middle lobes horizontal fissure
high pitched musical squeaking sounds that sound polyphonic predominate in expiration wheeze- high pitched Low-pitched; monophonic single note; musical snoring; moaning sounds that are heard throughout the cycle; may clear somewhat by coughing wheeze- low pitched High-pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall stridor resemble low pitched wheezes rhonchi four main functions of respiratory system supplying o2 to body for energy production, removing co2 as a waste product, maintaining homeostasis, heat exchange seven parts of subjective data cough, sob, chest pain w breathing, history of respiratory infections, smoking history, environmental exposure, patient centered care what are the 5 As
ask advise assess assist arrange 4 parts of objective data inspection palpation percussion auscultation concentrated watching, close careful scrutiny, begins when you meet patient and get general survey inspection confirms what you noted in inspection, applies sense of touch to assess texture, temperature, moisture, organ location and size palpation tapping the person's skin with short, sharp strokes to assess underlying structures percussion
