HEALTH ASSESSMENT IN NURSING WITH CORRECT QUESTIONS AND ANSWERS 100%.

.A-delta primary afferent fibers - ANSWER--small-diameter -lightly myelinated -transmit fast pain to spinal cord within 0.1 second -felt by pricking, sharp, or electric-quality sensation and usually is caused by mechanical or thermal stimuli .acanthosis nigricans - ANSWER-velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla .accommodation - ANSWER-adapting our current understandings (schemas) to incorporate new information; modification .actual diagnoses - ANSWER-nursing diagnoses (from NANDA) related to etiology (cause) as evidenced by defining characteristics (what you see or observe) .African traditions - ANSWER--traditional healers: magico herbalist, hoodoo, or other traditional healers known as "old lady," "granny," or lay midwife -preventive and healing practices: magical and herbal mix of herbs, roots, and rituals, talismans or amulets .age-related macular degeneration (AMD) - ANSWER-a major cause of visual impairment that affects the macula portion of the retina -causes deterioration of macula (central area of retina) -the macula processes sharp, clear, straight-ahead vision -damage to macula results in blind spots and blurred or distorted vision .anatomic variation - ANSWER-lower extremity venous valves vary between caucasians and african blacks; african blacks have been noted to have fewer valves in the external iliac veins but many more valves lower in the leg than do caucasians. African blacks have lower varicose vein presence .approach for spiritual assessment - ANSWER--no absolute in the timing of a spiritual assessment -should not be viewed as static but rather as an ongoing conversation between the nurse and the client -some professionals want assessment done with initial assessment -some believe it should be done after the nurse-client relationship has been established - the CLIENT is the FOCUS of the spiritual assessment .arcus senilis - ANSWER-a normal condition in older clients, appears as a white arc around the limbus; has no effect on vision .Asian traditions - ANSWER--healers: chinese medical practitioners, herbalists -preventive and healing practices: prevent or rebalance yin/yang, hot/cold foods and conditions, wear amulets, acupuncture, cupping, moxibustion .assimilation - ANSWER-interpreting one's new experience in terms of one's existing schemas .assimilation with culture - ANSWER-the gradual adoption and incorporation of characteristics of the prevailing culture .auscultation - ANSWER-the sounds detected using auscultation are classified according to intensity (loud or soft), pitch (high or low), duration (length), and quality(musical, crackling, raspy) of sound .axillary temp - ANSWER-35.4-37.0C 95.6-98.5F .barriers from deceased donors (blood products, transfusions, and organ donation): - ANSWER--lack of awareness of transplantation -religious or cultural distrust of the medical community -fear of medical abandonment (if donating) -fear of racism .barriers from living donors (blood products, transfusions, and organ donation): - ANSWER--unwillingness to donate -medical comorbid conditions -distrust or fear of medical community -loss to follow-up (return for follow-up) -poor coping mechanisms -financial concerns -reluctance to ask family members and friends -fear of surgery -lack of awareness about living donor kidney transplantation .bell of stethoscope - ANSWER-used to detect low-pitched sounds .benefits of spiritual care to the client: - ANSWER--support for healthy grieving -support for improved self-esteem and confidence -assistance with maximization of potential in the current circumstances -support to improve relationships with self, others, and with an absolute/God -assistance in renewing a sense of meaning and hope -enhancement of the client's sense of belonging -assistance in improving problem solving -help with enduring problems that cannot be solved and with continuing distress and disability -help in finding renewed hope .binocular vision - ANSWER-"two-eyed" vision .blunt percussion - ANSWER-used to detect tenderness over organs .BMI - ANSWER- .body mass index - ANSWER-see page 233 .C-fibers - ANSWER--unmyelinated -primary afferent fibers -transmit slow pain within 1 second -felt as burning, throbbing, or aching -caused by mechanical, thermal, or chemical stimuli -resulting in tissue damage .cardiac output - ANSWER-the more blood the heart pumps, the greater the pressure in the blood vessels; ex. BP increases during exercise .cataracts - ANSWER--leading cause of blindness -preventable -clouding of the lens of the eye; vision affected more at night .Changes in BP and recommendations for follow-up - ANSWER-normal 120-129/80-84= prehypertension- recheck 2yrs borderline 130-139/85-89= prehypertension- recheck 1 yr Hypertension >140/90= hypertension -stage 1: 140-159/90-99= stage 1- confirm within 2 months -stage 2: 160-179/100-109= stage 2- eval or refer to source of care within 1 month -stage 3: >180/110= stage 2- eval and treat immed. within 1 week .characteristics of religion - ANSWER--formal -organized -group oriented -ritualistic -objective, easily measurable .characteristics of spiritual assessment - ANSWER--formal or informal -respectful -nonbiased .characteristics of spiritual care - ANSWER--individualistic -client oriented -collaborative .characteristics of spirituality - ANSWER--informal -nonorganized -self-reflective -may involve spirtual experiences -subjective, difficult to measure .cholesterol - ANSWER-important to normal bodily functions; necessary component of bile salts that aid in digestion .circulating blood volume - ANSWER-an increase in the volume will increase BP. A sudden drop in BP may indicate a sudden blood loss, as with internal bleeding; orthostatic BP is when the patient stands up and BP changes .closed-ended questions - ANSWER-To obtain facts and to focus on specific info; keep interview on course; clarify or obtain more accurate info; .coining in Asian culture - ANSWER- .COLDSPA - ANSWER-c-characteristics: describe the symptoms o- on-sent: when did it start L- location: where is it, does if radiate, occur anywhere else D-duration: how long does the pain last S- severity- pain (use scale 1-10 if able) P- pattern: what makes it better or worse A- associated factors: what else is going on .collaborative problems and referrals - ANSWER-should be documented as risk for complications .collecting objective data - ANSWER--physical characteristics (skin color, posture) -body functions (heart rate, resp. rate) -appearance (dress and hygiene) -behavior (mood, affect) -measurements (blood pressure, temperature, height, weight) -results of lab testing (platelet count, x-ray finding) .cornea - ANSWER--permits the entrance of light, which passes through the lens to the retina -"window of the eye" .culture - ANSWER-learned and shared .cupping - ANSWER-medicine practice in Asian culture that can be misinterpreted .cyanosis - ANSWER-may cause white skin to appear blue-tinged, especially in the perioral, nail bed, and conjunctival area. dark skin may appear blue, dull, and lifeless .cyanosis of lower lid - ANSWER-suggests heart or lung disorder .data analysis - ANSWER-seven steps: -identify abnormal data and strengths -cluster the data -draw inferences and identify problems -propose possible nursing diagnoses -check for defining characteristics of those diagnoses -confirm or rule out nursing diagnoses -document conclusions .deep palpation - ANSWER-place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure; allows to feel deep organs or structures covered by muscle .definition of health - ANSWER-as defined by WHO is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity .dehydration - ANSWER--can have a seriously damaging effect on body cells and the execution of body function -cramps, dry mouth, headache, excessive thirst .diaphragm of the stethoscope - ANSWER-used to detect high-pitched sounds .dietary considerations in cultural assessment include: - ANSWER--the meaning of food to the individual -common foods eaten and rituals surrounding the eating -the distribution of food throughout a 24-hour day -religious beliefs about food -beliefs about food and health promotion -nutritional deficiencies associated with the ethnic group .direct percussion - ANSWER-direct tapping of a body part with one or two fingertips to elicit possible tenderness .Dullness (heard over more solid tissue) - ANSWER-Intensity: medium Pitch: medium Length: moderate Quality: thud-like Example of origin: diaphragm, pleural effusion, liver .E chart - ANSWER-a tool used to test visual acuity, especially useful for patients who cannot read or speak english .ears (variations) - ANSWER--hearing loss may result from genetic causes, complications at birth, certain infectious diseases, chronic ear infections, the use of particular drugs, exposure to excessive noise and aging -half of all cases are avoidable through primary prevention .EHRs focus on - ANSWER-Total health (emotional, physical, social, spiritual); may be used by a variety of healthcare providers .Elasticity of vessel walls - ANSWER-an increase in stiffness of the vessel walls will increase BP; ex. atherosclerotic changes .Electronic health record (EHR) - ANSWER-comprehensive health status of the client and not only the medical status; may be used by a variety of health care providers and focus on the total health of the client .Electronic medical record (EMR) - ANSWER-medical records supplied by physicians who made medical diagnoses and prescribed treatments .entropian and ectropian - ANSWER--entropian: inverted lower lid; can cause pain and injure the cornea -ectropian: everted eye lid; results in exposure and drying of conjunctiva .Erikson theory - ANSWER-a psychosocial theory, with psychosocial being defined as the intrapersonal and interpersonal responses .Erikson's Eight stages of psychosocial development - ANSWER- .erythema - ANSWER-skin redness and warmth, seen in inflammation, allergic reactions, or trauma .essential elements of critical thinking - ANSWER--keep an open mind -use rationale to support opinions or decisions -reflect on thoughts before reaching a conclusion -use past clinical experiences to build knowledge -acquire an adequate knowledge base that continues to build -be aware of interactions of others -be aware of environment .ethnicity - ANSWER-a socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come in contact with .ethnocentrism - ANSWER-the universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways .evaluating nutritional disorders- Eyes - ANSWER--sign or symptoms: night blindness; corneal swelling, softening, or dryness; red conjunctiva; gray patches on conjunctiva -implications: Vit. A def.; riboflavin def. .evaluating nutritional disorders- general - ANSWER--signs or symptoms: weakness and fatigue, weight loss -implications: anemia or electrolyte imbalance, decreased calorie intake, increased calorie use, or inadequate nutrient intake or absorption .evaluating nutritional disorders- skin, hair, and nails - ANSWER--sign or symptoms: dry, flaky skin; dry skin with poor tugor; rough, scaly skin with bumps; petechiae or ecchymoses; sore that will not heal; thinning, dry hair; spoon-shaped, brittle or ridged nails -implications: Vit. A, Vit. B-complex, or linoleic acid defiency; dehydration; Vit. A def.; Vit. K or C def.; protein, Vit C, zinc def.; iron def.; .extraocular muscles - ANSWER--the six muscles attached to the outer surface of each eyeball -innervation supplied by three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI) .eyelids - ANSWER--protect the eye from foreign bodies and limit the amount of light entering the eye -serve to distribute tears that lubricate the surface of the eye -join at two parts : the lateral (outer) cathus and medial (inner) canthus -medial canthus contains the puncta which is two small openings that allow drainage of tears into the lacrimal system .eyes (variations) - ANSWER--visual impairment varies across age, gender, and geography -in highly developed countries, cataract is the leading cause of visual disease and blindness -followed by glaucoma and age-related macular degeneration .factors affecting mental health - ANSWER--economic and social factors -unhealthy life choices-substance abuse -exposure to violence -personality factors -spiritual factors -cultural -change or impairment in neurologic system -psychosocial development level .FLACC scale - ANSWER- .Flatness (heard over very dense tissue) - ANSWER-Intensity: soft Pitch: high Length: short Quality: flat Example of origin: muscle, bone, sternum, thigh .formal technique for spiritual assessment - ANSWER--HOPE -FICA - both of these are paper-and-pencil self-response and begin a dialogue .four assessment techniques (nclex) - ANSWER-inspection, palpation, percussion, and auscultation