PNU 120 Exam 1 questions and answers study guide correct and verified 100%

PNU 120 Exam 1 questions and answers study guide correct and verified 100%PNU 120 Exam 1 questions and answers study guide correct and verified 100% Health History Components - correct answers-Includes: 1: Demographic Information 2: Source of History 3: Chief Concern 4: History of Present Illness 5: Past Health History / Current Health Status 6: Family History 7: Psychosocial History 8. Health Promotion Behaviors Physical Assessment Techniques (Order) - correct answers-1. Inspection 2. Auscultation 3. Palpation 4. Percussion (abdomen is the exception: inspect, auscultate, percuss then palpate) Health Promotion Behaviors - correct answers-heath history component - exercise/activity, diet, sun exposure, safety equipment, substance use, environmental exposure/home environment, resources, stress, sleep patterns, coping measures - awareness of risks for heart disease, cancer, diabetes, stroke Light Palpation vs Deep Palpation - correct answers-Light Palpation: Less than 1 cm (0.4 inch) Deep Palpation: 4 cm (1.6 inch) for abdominal organs / masses General Survey - correct answers-A written summary of the impression of the client's overall health. The nurse gathers this information from the first encounter with the client and continues to make observations throughout the assessment process. a) Physical appearance b) Body structure c) Mobility d) Behavior e) Vital signs Nursing Process Framework Order - correct answers-assessment, analysis/data collection, planning, implementation, evaluation Assessment/Data collection - correct answers-Involves the systematic collection of information about clients' present health status to identify needs and additional data to collect based on findings. Subjective Data - correct answers-What the client tells the nurse. Ex: "my shoulder is really sore." Objective Data - correct answers-Data the nurse obtains through observation and examination. Ex: Client grimaces when attempting to brush their hair with the left arm Analysis/Data Collection - correct answers-Nurses use critical thinking skills to identify clients health statuses or problems, interpret/monitor the collection database, reach an appropriate nursing judgement about health status and provide nursing care Planning - correct answers-Nurses must establish priorities and optimal outcomes of care they can readily measure and evaluate. Implementation - correct answers-Nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the nursing process. Evaluation - correct answers-Nurses' evaluate clients responses to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes. Sources of Data for Collection and Assessment - correct answers-Observation, interviews with clients and families, medical history, comprehensive / focused physical assessment, etc. Critical Thinking and the Nursing Process - correct answers-Assessment / Data Collection: Collect information about a clients present health to identify needs and to identify additional data to collect based on findings. Critical Thinking Skills - correct answers-Observe Use Correct Techniques for Collecting Data Differentiate between irrelevant and relevant data Organize, categorize and validate data Interpret assessment data and draw conclusion Identify clusters and cues Recognize actual problems Identify goals and outcomes for client care Determine accuracy of theories and understanding of teachings Oral Hygiene - correct answers-Helps decrease the risk of infection for clients living in long term facilities, especially from the transmission of pathogens that cause pneumonia. Other populations who require meticulous oral hygiene: Those who are seriously ill, injured, unconscious, dehydrated, or have an altered mental health status or limited upper body mobility. Foot Care - correct answers-Foot care prevents skin breakdown, pain and infection. EXTREMELY IMPORTANT for those who have diabetes mellitus, and a qualified professional must perform it. Lifting Clients Safety - correct answers-Have a wide stance (base of support) Distribute your weight evenly Tighten abdominal muscles to prevent back strain Keep the object close to you Pull object toward the center of gravity If lifting from the floor, flex your back, hips and knees Positioning Clients - correct answers-HAVE MULTIPLE STAFF MEMBERS ASSIST WHEN MOVING A CLIENT! Fowler's position 45°-60° -Semi Fowler's 15°-45° -High Fowler's 60°-90° -Orthopneic -Dorsal Recumbant (Supine) -Prone -Lateral -Sim's When determining how to transfer a client: - correct answers-Determine the client's ability to help with the transfer (balance, muscle strength, endurance, etc.) Assess and monitor