BSMCON NUR 2102 TEST 1 WITH COMPLETE ANSWERS 2023 Graded A+

BSMCON NUR 2102 TEST 1 WITH COMPLETE ANSWERS 2023 Graded A+. Biographical Data - ANSWER Name, Gender, Address, phone number, email address, birth date, birthplace, race/ethnicity, religion, marital status, occupation, contact person, and source of data Reason for Seeking Health Care - ANSWER Chief complaint (CC) or presenting problem History of Present illness - ANSWER Conduct a symptom analysis - include OLDCARTS Present Health Status - ANSWER Focus on patient condition's (acute and chronic), medications the patient is currently taking, and allergies the patient has experienced. Past Health History - ANSWER Explore past and present conditions that may have some effect on patient's current health needs and problems. Family History - ANSWER Review of patient's blood relatives (biologic), spouse and children to identify illnesses of genetic, familial or environmental nature that may affect the patient's current or future health. Personal and Psychosocial History - ANSWER Explores a variety of topics, including any information that affects the patient's physical and mental health. Review of Systems - ANSWER Conducted to inquire about past & present health of each of the patient's body systems. Use OLDCARTS. If sufficient data has been collected about the body system in the Present Illness/Present Health status section, these questions are not repeated. No delegation to NAP. The RN is not only responsible for gathering data, but clustering it and using it in decision making. The delegating nurse retains responsibility and accountability for nursing care of the client, including nursing assessment, planning, evaluation, documentation, and supervision. The delegating nurse shall assess the clinical status and stability of the client's condition; determine the type, complexity, and frequency of the nursing care needed; and delegate only those tasks that: a. Do not require the exercise of independent nursing judgment; b. Do not require complex observations or critical decisions with respect to the nursing task or procedure; c. Frequently recur in the routine care of the client or group of clients; d. Do not require repeated performance of nursing assessments; e. Utilize a standard procedure in which the tasks or procedures can be performed according to exact, unchanging directions; and f. Have predictable results and for which the consequences of performing the task or procedures improperly are minimal and not life threatening. 2. The delegating nurse shall also assess the training, skills, and experience of the unlicensed person and shall verify the competency of the unlicensed person to determine which tasks are appropriate for that unlicensed person and the method of supervision required. - ANSWER According to the ANA Standards of Practice, what is the registered nurse's role in assessment? Primary prevention - ANSWER Prevent disease from developing through healthy lifestyle Secondary prevention - ANSWER Screening efforts to promote the detection of disease to halt the progression the disease process Tertiary prevention - ANSWER Minimizing the disability from acute or chronic disease or injury Help the client maximize his or her health Health promotion - ANSWER Behavior motivated by the desire to increase well-being and actualize human health potential Health protection - ANSWER Behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness Clinical prevention - ANSWER Individually focused interventions such as immunization, screenings, and counseling, aimed at preventing escalation of diseases and conditions How does QSEN relate to health assessment? - ANSWER Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, informatics The RN is not only responsible for gathering data, but clustering it and using it in decision making. culture - ANSWER all the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways, and characteristics that influence a worldview ethnicity - ANSWER characteristics that a group may share in some combination such as common geographic origin Language and dialect, history, lifestyle, and/or religious beliefs, shared tradition and symbols, music preferences race - ANSWER genetic in origin and includes physical characteristics. Individuals from same racial group are not necessarily the same culture. cultural sensitivity or cultural humility - ANSWER Culturally-competent care- new terminology be culturally sensitive, don't stereotype, use a template for assessment - ANSWER cultural and ethical considerations Comprehensive Problem-based/focused assessment Episodic/follow-up assessment Screening assessment - ANSWER 4 types of health assessment Components of health assessment- health history (subjective), physical exam (objective)- includes lab and dx tests, and documentation - ANSWER components of health assessment Clinical Judgment - ANSWER Noticing, Interpreting, Responding, Reflecting Requires accurate assessment data Influenced by: Experience, Knowledge, Attitude, perspectives; Nurse's Knowledge, Experience, Ethical Perspective, Knowing the Patient introduction, discussion, summary - ANSWER 3 phases of the interview Biographic data Reason for seeking care Present health status Past medical history Family history Personal and psychosocial history Review of all body systems - ANSWER Components of the Comprehensive Health History PE relevant to anatomy present without assumptions Sensitive history taking Consider potential prior negative experiences Gender affirming approach Examination only if body parts are pertinent to visit Hormone therapy patients --> secondary sex characteristics - ANSWER considerations for Transgender patients Vital Signs: T, P, R, BP and O2 saturation Neurologic: Oriented to person, place, time and situation. Communication: Speech clear and appropriate Cardiac: S1 and S2, Rate, Rhythm, Radial and pedal pulse, Warmth of extremities, capillary refill Lungs and respiratory system: ease of breathing, skin color, symmetry of thorax, lung sounds Abdomen and GI system: Appearance of abdomen, bowel sounds, light palpation of the abdomen Musculoskeletal system: Compare for symmetry Skin: Turgor and intactness EQUIPMENT: catheters, or tubes—location, patency and description of drainage - ANSWER Common data collected during the shift assessment genetics - ANSWER the study of heredity; examines the function and composition of a single gene genomics - ANSWER the study of genes and their function; incorporates all the genes and their interrelationships so as to understand their combined effect on growth and development required competencies of the RN - ANSWER *Demonstrates an understanding of the relationship of genetics/genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness *Demonstrates ability to elicit a minimum of three generation family health history information *Constructs pedigree from collected family history information using standardized symbols and terminology *Collects personal, health and developmental histories that consider genetic, environmental, and genomic influences and risks *Conducts comprehensive health and physical assessments that incorporates knowledge about genetic, environmental, and genomic influences and risk factors *Critically analyzes the history and physical assessment findings for genetic, environmental, and genomic influences and risk factors *Assesses clients' knowledge, perceptions, and responses to genetic and genomic information *Develops plan of care that incorporates genetic and genomic assessment information Four Basic Techniques of Physical Assessment - ANSWER inspection, palpation, percussion, auscultation inspection - ANSWER What do I see? All body systems included Always first Provide appropriate drape Seems easy, need practice to master Possible equipment: penlight, otoscope, ophthalmoscope, speculum palpation - ANSWER What do I feel? For: texture, size, shape, consistency, location, identify painful areas Palmar surface and finger tips Light- 1cm (always first) Deep- 4cm Dorsal surface for temperature Gentle touch, warm hands, and short nails to prevent discomfort or injury to client Touch has cultural symbolism and significance. State purpose, manner, and location of touching. Wear gloves when palpating mucous membranes or other areas where contact with body fluids is possible. PAINFUL AREAS LAST percussion - ANSWER What do I hear? Evaluate: size, borders, consistency, tenderness, fluid Five tones: Tympany- loud, high-pitch- abdomen Resonance- normal lung tissue Hyperresonance- overinflated lungs such as emphysema Dullness- over liver and solid organs Flatness- bones and muscle auscultation - ANSWER What do I hear? Listening to sounds within the body Uses stethoscope- blocks out extraneous sounds Listen for sound and characteristics: Intensity Pitch Duration Quality Helpful tip: close your eyes when listening to block out other sensory information Optimize quality: Quiet room Place stethoscope DIRECTLY on skin NOT over top of clothes Friction of body hair can sound like abnormal sounds- crackles in the lungs things to remember about pulse ox - ANSWER Finger nail polish usually has to be removed in order to get an accurate reading Fingers needs to be warmed Can also use ear lobe Toes are often used in infants Baseline indicators of client's health status - ANSWER Temperature Heart rate Respiratory rate Blood pressure Oxygen saturation Height Weight standard assessment data - ANSWER Pain assessment is also known as 2.2 - ANSWER 1 kg = ? lbs 1 - ANSWER 1 L = ? kg 2.2 - ANSWER 1 L = ? lbs BP= CO X SVR - ANSWER hypotension - ANSWER Usually systolic < 90 mm Hg Can be due to: Fluid depletion Heart failure Vasodilation Medication orthostatic hypotension - ANSWER If the client experiences SBP decreases more than 20 mm Hg and/or DBP decreases more than 10 mm Hg with a 10-20% increase in HR Patients often also c/o dizziness how to determine desirable body weight (DBW) - ANSWER Females- 100 lbs for 5' and 5 lbs for each inch over 5' +- 10% for small or large frame Males- 106 lbs for 5 ft + 6 lbs for each inch over 5' +- 10% for small or large frame normal range - respiratory rate - ANSWER 12-20 adult 15-20 adolescent 15-25 school age child 20-40 toddler 30-80 newborn normal range - pulse/heart rate - ANSWER 60-100 adult 50-90 adolescent 75-120 school age child 80-140 toddler 80-180 newborn normal range - BP - ANSWER < 120/80 normal range - oral temp - ANSWER 96.4-99.1 F axillary temp - ANSWER typically 1 degree less than oral temp rectal temp - ANSWER typical 1 degree more than oral temp formulas to determine BMI - ANSWER Weight (kg) / Height (m2) Weight (lb)x 705/ Height (in2) BMI stages/ranges - ANSWER Normal BMI is between 18.5 and 24.9 25-29.9 Overweight 30-34.9 Obesity Class I 35-39.9 Obesity Class II >40 Obesity Class III (extreme obesity) Normal waist circumference - ANSWER Normal- females: less than or equal to 35 in. Normal- males: less than or equal to 40 in. hyperlipidemia - ANSWER associated with elevated serum lipids including cholesterol, triglycerides, and phospholipids not associated with clinical symptoms until cardiovascular event occurs. Biochemical indications = elevations in serum lipids In adults, cholesterol levels from 200 to 239 mg/dl considered borderline-high. Levels of 240 mg/dl or higher are considered high. biochemical indications of poor nutrition - ANSWER low serum levels of albumin or protein.