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Nursing 125 Midterm Exam with Complete Solutions

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Nursing 125 Midterm Exam with Complete Solutions

Instelling
Nurs 125
Vak
Nurs 125

Voorbeeld van de inhoud

Nursing 125 Midterm Exam with
Complete Solutions

subjective data - correct Answer-information given by the patient during health history
about themselves

objective data - correct Answer-information observed by the nurse during physical
assessment

primary data source - correct Answer-patient

secondary data source - correct Answer-data derived from charts, family members,
anything other than the patient

emergent health history - correct Answer-reason for seeking care, current health
concerns, medications, allergies. no details until patient is stable

focused health history - correct Answer-questions related to current situation, ie chief
concern

comprehensive health history - correct Answer-demographic data, full description of the
reason for seeking care (chief concern), history of present illness (symptom analysis),
past health history, current medications, family history, personal and social history,
growth and development info for children and infants, review of systems.

demographic data - correct Answer-patient's name and personal info, often filled out in a
form. also includes info abt recent disease exposure, travel, contact w pollution and
allergens. may assess living arrangements for hospital patients to determine level of
independence needed for discharge.

chief concern - correct Answer-reason for seeking care

history of present illness (symptom analysis) - correct Answer-location, quality,
severity/quantity, timing (onset, duration, constancy, patterns), aggravating factors,
alleviating factors, associated signs and symptoms, environmental factors, significance
to patient, patient perspective

past health history - correct Answer-medical/surgical conditions, treatments given,
injuries, chronic conditions, OB GYN history (first period, last period, menopause?
pregnancies?), immunization history, childhood illnesses, routine screening test dates
and results, last physical exam date

,current medications - correct Answer-note name, dose, route and purpose. note
allergies, don't confuse side effects w allergy.

family history - correct Answer-identify areas of familial concern and areas for health
promotion. identify history of cancer, heart disease, diabetes, etc.

personal and social history - correct Answer-marital status, children, significant life
experiences, occupation, housing, safety, mental health issues, memory and cognition,
culture, language, recreation and hobbies, spiritual beliefs

growth and development info - correct Answer-for babies and young children, identify
genetic background, motor skills, speech, developmental milestones

review of systems - correct Answer-review history and subjective data of each body
system. use common language and do health promo

primary reason patients access healthcare - correct Answer-pain

pain is - correct Answer-what the patient says it is

acute pain - correct Answer-result of tissue damage with an easily identifiable cause. it
is intense, localized, and has a protective function

recurrent acute pain - correct Answer-brief pain episodes that occur at intervals.
protective, result of injury or inflammation. ex: migraines

chronic pain - correct Answer-lasts 3+ months. not always protective. may start as
acute, may continue for life. starts slow, builds gradually. may not have identifiable
cause. can become more severe due to changes in how the body transmits the pain
signal

signs and symptoms of acute pain - correct Answer-elevated resp rate, elevated heart
rate, high blood pressure, diaphoresis (sweating), nausea and vomiting, muscle
spasms, guarding the site, restlessness, anxiety and distress, seeking help

signs and symptoms of chronic pain - correct Answer-normal vitals, no diaphoresis,
reduced functional abilities, sleep and appetite changes, depression, suicidal, apathy,
lethargy, decreased concentration, decreased libido, social withdrawal, excessive
diagnosis/cure seeking

neuropathic pain - correct Answer-caused by nerve damage. very painful and difficult to
treat. can be acute or chronic

nociceptive pain - correct Answer-pain from a normal process that results in noxious
stimuli being perceived as painful

, referred pain - correct Answer-travels along a dermatome

visceral pain - correct Answer-felt in abdominal organs

somatic pain - correct Answer-originates in skin, muscles, bones and joints

cutaneous pain - correct Answer-derives from the dermis, epidermis, and subcutaneous
tissues

phantom pain - correct Answer-felt in an amputated limb

one dimensional pain scale - correct Answer-patient self reports pain intensity on a
scale of 1-10

multidimensional pain scale - correct Answer-Mcgill scale, brief pain inventory. often
used in chronic pain patients. includes many aspects of pain assessment

faces pain scale - correct Answer-used in children or nonverbal patients

FLACC pain scale - correct Answer-F: Faces.
L: Legs.
A: Activity.
C: Cry
C: Consolability

used in babies 0-3 years

older adult pain - correct Answer-pain viewed as natural component of aging process,
may be ignored and undertreating by healthcare providers. pain may also be
underreported and patients may not take meds

PAINAID scale - correct Answer-used for patients with dementia. breathing, negative
vocalization, facial expression, body language, consolability

vital signs - correct Answer-temperature, pulse, respirations, blood pressure. sometimes
O2 saturation. informally includes pain.

when are vital signs taken - correct Answer-on admission, routinely in acute care, when
patients deteriorate, before and after invasive procedures, before and after certain
medications, when required

acute general survey findings - correct Answer-anxiety, acute distress, pallor, cyanosis,
change in mental status

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