Nursing 251 Exam 1 questions with correct answers

The Nursing Process A systemic problem solving approach to identify and treating human response to actual or potential health problems 5 phases of the Nursing Process assessment diagnosis planning implementation evaluation Example of the Nursing process A: reddened area on patients sacral area D:Potentital for impaired skin integrity, could be because of excessive bed rest P:patient will maintain intact skin while in hospital I: Make sure patient is moved frequently E:look at spot again, decide weather medication is needed or if healing on own. If needs more repeat steps. Nursing Diagnosis Defined by "NANDA" as a clinical judgment about clients, family, community responses to actual or potential health problems. Assessment to establish a data base regarding the clients wellness, health practices, past illnesses or experiences and establishing health care goals Reasons determine the reason for seeking help establish baseline of health status determine strengths and weaknesses integrate previous health responses to current status identify cultural influences on health Method History observations physical exam results of lab and diagnostic tests Data descriptive, concise, and complete not judgmental or interpretive statements subjective data This come from the client (Subject). Things they say... ie. pain objective data what you see. IE. redness, swelling, appearance Four types of Assessment Initial/Comprehensive ongoing/partial assessment focused/problem assessment emergency assessment initial/comprehensive assessment occurs when the client FIRST presents to a health care system. All inclusive/overall picture of health collect subjective and objective data ongoing/partial assessment occurs after comprehensive data base is established. Reassessment of initial problem/baseline. Looking for improvement or deterioration focused/problem assessment occurs in relation to a specific health concern, does not replace comprehensive assessment. Follow up with comprehensive. Emergency assessment Occurs rapidly when life saving action needs to be taken (i.e. car accident) Steps of health assessment Subjective Data objective Data primary (client) &secondary (family) sources of data Validation of Data Documentation of all Data process of data analysis identify abnormal data cluster data draw inferences and identify problems purpose nursing diagnosis check defining characteristics of diagnosis confirm/rule out Validating Data crucial first step of nursing process prevents inaccurate data recheck/repeat clarify verify compare Hand washing the most effective way to prevent the spread of disease HIPAA Health Insurance Portability Accountability Act General impression of Patient begins when you first meet the patient and continues through the health assessment, physical examination, and closing overall impressions signs of distress mobility body build behavior 4 primary techniques inspection palpation percussion auscultation (stethoscope) Know Normal but... nothing is normal inspection uses sense to observe general survey considerations for inspection direct vision is necessary lighting what can inspection tell us? abnormalities/signs of distress surface characteristics unusual odors symmetry vs asymmetry palpation the use of tactile sense (touch and feel) to further emphasize visual findings or identify findings not seen looks for rough/smooth, temperature, moisture, mobility, consistency, strength of pulses, size, shape, and degree of tenderness percussion sound auscultation heart sounds lung sounds bowel sounds turbulence in blood flow types of pain cutaneous pain- cut deep somatic pain- sprained ankle visceral pain-burst/cyst on ovary referred pain- heart attack symptoms radiating pain- heart, abdominal surgery (pulsating) Characteristics of pain C: character O: onset L: location D: duration S: severity P: pattern A: associated factors Cultural and spiritual assessment helps you better understand someones belief to help them better includes customs, beliefs, and values Belief assessment what caused the problem? why do you think it started when it did? What does your sickness do to you? How severe? etc Developing cultural sensitivity recognize that cultural diversity exists demonstrate respect respect the unfamiliar identify and examine your own beliefs modify health care for specific client Central Nervous System Contains the brain and spinal cord Peripheral nervous system everything else-extending nerves Cerebrum Frontal, parietal, temporal, and occipital lobes Meninges Duramate, arachnoid, and pia mater Cerebellum reflex control of muscle tone, coordination, equilibrium Brainstem midbrains, pons, medulla wakefullness NOT awareness Sensory pathway receptor-->sensory nerve-->peripheral nerve-->spinal cord-->thalamus-->cerebral cortex Neurological assessment Own history, family history, history of smoking/alcohol use, medical history, present symptoms, trauma, notes of hygiene, dress, grooming, manner and affect etc Pain Response Central: sternal rub, trap squeeze, subaorbital pressure, mandibular pressure peripheral: nail bed pressure, pinch inner bicep/tricep level of consciousness Awareness Arousal Brainstem-->RA's-->eye opening, motor responses Awareness cerebrum -->orientation, knowledge, judgment Categories of levels of consciousness Alert-awake, responds immediately and appropriately confused- inappropriate responses to stimuli obtuned-drowsy, sleepy, dehydrated stuporus- semi comatose: simple motor/verbal responses to pain comatose: no responses Orientation to person place time and event (Ox4) to person place and time (o X3) if alert and oriented (A+Ox3) Immediate recall Temporal lobe- give client few things to remember and ask them to repeat them back to you in a few minutes recent memory the past 2 days, ask client if they remember what they had for breakfast remote memory frontal lobe, this doesn't go away so ask them where they went to HS/or middle school based on age Language Fluency dysarthria impairment of speech, poor articulation aphasia absence of the ability to communicate confabulation fabricating stories perservarion repeating the same words to questions abstraction client explains the meaning of a fable/proverb computation simple calculations comprehension ability to learn general knowledge ask client about who the current president is judgement "if this building was burning down what would you do?" this question tests... motor response response to verbal, tactile, or painful stimuli muscle strength and symmetry muscle tone: firm, flaccid, spasticity grade motor response 0-5 scale (5 is normal) Palmar (pronator) drift clients ability to hold arms out in front of body- irregular if falls Motor frontal lobe, muscle strength scale, scale of 0-5 principles: always on a scale out of 5, strength is tested with "normal" movement Abnormal Motor Responses flexion/decorticate-inward extension/decerebate-outward abnormalities in awake patients plegiavs paresis pronator drift lower extremity drift