Health Assessment Exam 1
___ in every ___ residents belongs to a *group other than single-race, non-Hispanic White.* -
ANS-*One* in every *three* residents belongs to a *group other than single-race, non-Hispanic
White.*
\* Empathy* - ANS-*Empathy* means viewing the world from the other person's inner frame of
reference while remaining yourself.
\* External factors* - ANS-*External factors* relate mainly to the *physical setting.*
\* Heritage consistency* - ANS-*Heritage consistency* is the degree to which *a person's
lifestyle reflects his or her traditional heritage.* A person can possess values that are consistent
with the norms of the traditional culture or that are modern (or acculturated to the norms of the
dominant society). Heritage consistency includes determination of a person's *cultural, ethnic,
and religious background and socialization experiences.*
\*10 traps of interviewing* - ANS-*10 traps of interviewing*. These nonproductive verbal
messages include:
(1) Providing false assurance or reassurance,
(2) Giving unwanted advice,
(3) Using authority,
(4) Using avoidance language,
(5) Engaging in distancing,
(6) Using professional jargon,
(7) Using leading or biased questions,
(8) Talking too much,
(9) Interrupting,
(10) And using "why" questions.
\*Assessment* - ANS-*Assessment* is the collection of subjective and objective data about a
patient's health.
\*CAGE* test identify what? - ANS-*CAGE* test is a screening questionnaire to identify
excessive or uncontrolled drinking, such as:
- *C* Cut down - Have you ever thought you should cut down your drinking?
- *A* Annoyed - Have you ever been annoyed by criticism of your drinking?
- *G* Guilty - Have you ever felt guilty about your drinking?
- *E* Eye-opener - Do you drink in the morning (i.e. an eye-opener?)
If the person answers "yes" to 2 or more CAGE questions, you should suspect alcohol abuse
and continue with a more complete substnce abuse assessment.
\*Clarification* - ANS-*Clarification.* Use this when the person's word choice is ambiguous or
confusing (e.g., "Tell me what you mean by 'tired blood.' "). Clarification also is used to
,summarize the person's words, simplify the words to make them clearer, and then ask if you are
on the right track. You are asking for agreement, and the person can then confirm or deny your
understanding.
\*Communication* - ANS-*Communication* carries you and the patient through the interview.
Communication is the *exchange of information* so that each person clearly understands the
other.
\*complete health history data category 1.* - ANS-*complete health history data category 1.*
First, collect *biographic data*, such as the patient's name, address, and date of birth as well as
language and communication needs.
\*complete health history data category 2.* - ANS-*complete health history data category 2.*
Second, note the *source of the history*, which is usually the patient, but may be someone else,
such as a relative or interpreter.
\*complete health history data category 3.* - ANS-*complete health history data category 3.*
Third, obtain the *reason for seeking care*, formerly known as the chief complaint. In the
patient's own words, briefly describe the reason for the visit.
\*complete health history data category 4.* - ANS-*complete health history data category 4.*
Fourth, record the *present health or history of present illness*. For a well person, briefly note
the general state of health. For a sick person, chronologically record the reason for seeking
care. When a patient reports a symptom, perform a *symptom analysis*. If you find it helpful,
use the mnemonic PQRSTU to do this.
\*complete health history data category 5.* - ANS-*complete health history data category 5.*
Fifth, investigate *past health events*, such as illnesses, injuries, hospitalizations, and allergies
as well as current medications.
\*complete health history data category 6.* - ANS-*complete health history data category 6.*
Sixth, gather a *family history* to help detect health risks for the patient. To aid in this process,
draw a pedigree or genogram.
\*complete health history data category 7.* - ANS-*complete health history data category 7.*
Seventh, perform a *review of systems* to evaluate the past and present health of each body
system, double-check for significant data, and assess health promotion practices. For each
body system, assess for symptoms and health-promoting behaviors.
\*complete health history data category 8.* - ANS-*complete health history data category 8.*
Finally, perform a *functional assessment*, including activities of daily living, such as bathing
dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other factors.
\*Confrontation* - ANS-*Confrontation.* These responses now include your own thoughts and
feelings. Use this only when merited by the situation. If you use it too often, you take over at the
patient's expense. In the case of confrontation, you have observed a certain action, feeling, or
statement and you now focus the person's attention on it. You give your honest feedback about
what you see or feel.
\*Critical thinking* - ANS-*Critical thinking* is the multidimensional thinking process needed for
sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been
identified, including *setting priorities.*
\*Cultural care* - ANS-*Cultural care* is professional health care that is culturally sensitive,
appropriate, and competent. To develop cultural care, you must have knowledge of *your
,personal heritage* and the *heritage of the nursing profession, the health care system, and the
patient.*
\*Cultural conflicts* - ANS-*Cultural conflicts* between nurses and patients from diverse
backgrounds are related to *different time and relationship perceptions*. For example, in some
cultures, the past may influence health practices. When making decisions about health, patients
may rely on relationships with others, and their behavior may depend on the opinion of others.
\*Culture* has which four characteristics? - ANS-*Culture* has the following four characteristics:
(1) it is *learned* from birth through language acquisition and socialization.
(2) it is *shared* by all members of the same cultural group.
(3) it is *adapted* to specific conditions related to environmental and technical factors.
(4) it is *dynamic* and ever changing.
\*Diagnostic reasoning* - ANS-*Diagnostic reasoning* is the process of analyzing health data
and drawing conclusions to identify diagnoses.
\*Each person responds differently* to the same stimuli, regardless of the primary culture and
value system. You should *guard against stereotyping* individuals. You should also understand
*culture-bound syndromes,* which may have no equivalent from a biomedical perspective. -
ANS-...
\*Ethnicity* - ANS-*Ethnicity* pertains to membership in a social *group that claims to possess a
common* geographic origin, migratory status, religion, race, language, shared values, traditions
or symbols, and food preferences. One's cultural background is a fundamental component of
one's ethnic background.
\*Explanation* - ANS-*Explanation.* With these statements, you inform the person. You share
factual and objective information. This may be for orientation to the agency setting: "Your dinner
comes at 5:30 PM." Or, it may be to explain cause: "The reason you cannot eat or drink before
your blood test is that the food will change the test results."
\*Facilitation* - ANS-*Facilitation* These responses encourage the patient to say more, to
continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called general leads, these
responses show the person you are interested and will listen further. Simply maintaining eye
contact, shifting forward in your seat with increased attention, nodding "Yes," or using your hand
to gesture, "Yes, go on, I'm with you," encourage the person to continue talking.
\*First-level priority problems* - ANS-*First-level priority problems* are emergent,
life-threatening, and immediate, such as establishing an airway or supporting breathing.
\*Internal factors* - ANS-*Internal factors* are what *you* bring to the interview.
\*Interpretation* - ANS-*Interpretation.* This statement is not based on direct observation as
with confrontation, but it is based on your inference or conclusion. It links events, makes
associations, or implies cause: "It seems that every time you feel the stomach pain, you have
had some kind of stress in your life." Interpretation also ascribes feelings and helps the person
understand his or her own feelings in relation to the verbal message.
\*Nonverbal communications convey messages* from the sender to the receiver. Work to
develop the ability to read patients' nonverbal behaviors and to monitor your own nonverbal
communication. - ANS-...
\*Nonverbal modes of communication* - ANS-*Nonverbal modes of communication* include:
- Physical appearance,
, - Posture,
- Gestures,
- Facial expression,
- Eye contact,
- Voice, and
- Touch.
\*Objective data* - ANS-*Objective data* include information obtained by the health care
provider through physical assessment, the patient's record, and laboratory studies.
\*PQRSTU* - ANS-*PQRSTU* stands for *P*rovocative or palliative, *Q*uality or quantity,
*R*egion or radiation, *S*everity scale, *T*iming, and *U*nderstanding the patient's perception
of the problem.
\*Reflection* - ANS-*Reflection.* This response echoes the patient's words. Reflection is
repeating part of what the person has just said.
\*Religion* - ANS-*Religion* is the belief in a divine or superhuman power or powers to be
obeyed and worshipped as the creator or ruler of the universe.
\*Second-level priority problems* - ANS-*Second-level priority problems* are next in urgency.
They require prompt intervention to prevent deterioration, and may include a mental status
change or acute pain.
\*Silence* - ANS-Silence is golden after open-ended questions. Your silent attentiveness
communicates that the patient has time to think, to organize what he or she wishes to say
without interruption from you.
\*Socialization* - ANS-*Socialization* is the process of being raised within a culture and
acquiring the characteristics of the group. Education is a form of socialization.
\*Spirituality* - ANS-*Spirituality* is borne out of each person's unique life experience and his or
her personal effort to find purpose and meaning in life. Spirituality may be used to *find meaning
and purpose for illnesses.*
\*Subjective data* - ANS-*Subjective data* consist of information provided by the affected
individual.
\*The database* - ANS-The *database* is the totality of information available about the patient.
The purpose of assessment is to make a judgment or diagnosis.
\*Third-level priority problems* - ANS-*Third-level priority problems* are important to the
patient's health, but can be addressed after more urgent problems. Examples include lack of
knowledge or family coping.
\A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
B) used for a limited or short-term problem usually consisting of one problem, one cue complex,
or one body system.
C) used to evaluate cause and etiology of disease.
D) used to perform a thorough or comprehensive health history and physical examination. -
ANS-A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
Feedback: INCORRECT
___ in every ___ residents belongs to a *group other than single-race, non-Hispanic White.* -
ANS-*One* in every *three* residents belongs to a *group other than single-race, non-Hispanic
White.*
\* Empathy* - ANS-*Empathy* means viewing the world from the other person's inner frame of
reference while remaining yourself.
\* External factors* - ANS-*External factors* relate mainly to the *physical setting.*
\* Heritage consistency* - ANS-*Heritage consistency* is the degree to which *a person's
lifestyle reflects his or her traditional heritage.* A person can possess values that are consistent
with the norms of the traditional culture or that are modern (or acculturated to the norms of the
dominant society). Heritage consistency includes determination of a person's *cultural, ethnic,
and religious background and socialization experiences.*
\*10 traps of interviewing* - ANS-*10 traps of interviewing*. These nonproductive verbal
messages include:
(1) Providing false assurance or reassurance,
(2) Giving unwanted advice,
(3) Using authority,
(4) Using avoidance language,
(5) Engaging in distancing,
(6) Using professional jargon,
(7) Using leading or biased questions,
(8) Talking too much,
(9) Interrupting,
(10) And using "why" questions.
\*Assessment* - ANS-*Assessment* is the collection of subjective and objective data about a
patient's health.
\*CAGE* test identify what? - ANS-*CAGE* test is a screening questionnaire to identify
excessive or uncontrolled drinking, such as:
- *C* Cut down - Have you ever thought you should cut down your drinking?
- *A* Annoyed - Have you ever been annoyed by criticism of your drinking?
- *G* Guilty - Have you ever felt guilty about your drinking?
- *E* Eye-opener - Do you drink in the morning (i.e. an eye-opener?)
If the person answers "yes" to 2 or more CAGE questions, you should suspect alcohol abuse
and continue with a more complete substnce abuse assessment.
\*Clarification* - ANS-*Clarification.* Use this when the person's word choice is ambiguous or
confusing (e.g., "Tell me what you mean by 'tired blood.' "). Clarification also is used to
,summarize the person's words, simplify the words to make them clearer, and then ask if you are
on the right track. You are asking for agreement, and the person can then confirm or deny your
understanding.
\*Communication* - ANS-*Communication* carries you and the patient through the interview.
Communication is the *exchange of information* so that each person clearly understands the
other.
\*complete health history data category 1.* - ANS-*complete health history data category 1.*
First, collect *biographic data*, such as the patient's name, address, and date of birth as well as
language and communication needs.
\*complete health history data category 2.* - ANS-*complete health history data category 2.*
Second, note the *source of the history*, which is usually the patient, but may be someone else,
such as a relative or interpreter.
\*complete health history data category 3.* - ANS-*complete health history data category 3.*
Third, obtain the *reason for seeking care*, formerly known as the chief complaint. In the
patient's own words, briefly describe the reason for the visit.
\*complete health history data category 4.* - ANS-*complete health history data category 4.*
Fourth, record the *present health or history of present illness*. For a well person, briefly note
the general state of health. For a sick person, chronologically record the reason for seeking
care. When a patient reports a symptom, perform a *symptom analysis*. If you find it helpful,
use the mnemonic PQRSTU to do this.
\*complete health history data category 5.* - ANS-*complete health history data category 5.*
Fifth, investigate *past health events*, such as illnesses, injuries, hospitalizations, and allergies
as well as current medications.
\*complete health history data category 6.* - ANS-*complete health history data category 6.*
Sixth, gather a *family history* to help detect health risks for the patient. To aid in this process,
draw a pedigree or genogram.
\*complete health history data category 7.* - ANS-*complete health history data category 7.*
Seventh, perform a *review of systems* to evaluate the past and present health of each body
system, double-check for significant data, and assess health promotion practices. For each
body system, assess for symptoms and health-promoting behaviors.
\*complete health history data category 8.* - ANS-*complete health history data category 8.*
Finally, perform a *functional assessment*, including activities of daily living, such as bathing
dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other factors.
\*Confrontation* - ANS-*Confrontation.* These responses now include your own thoughts and
feelings. Use this only when merited by the situation. If you use it too often, you take over at the
patient's expense. In the case of confrontation, you have observed a certain action, feeling, or
statement and you now focus the person's attention on it. You give your honest feedback about
what you see or feel.
\*Critical thinking* - ANS-*Critical thinking* is the multidimensional thinking process needed for
sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been
identified, including *setting priorities.*
\*Cultural care* - ANS-*Cultural care* is professional health care that is culturally sensitive,
appropriate, and competent. To develop cultural care, you must have knowledge of *your
,personal heritage* and the *heritage of the nursing profession, the health care system, and the
patient.*
\*Cultural conflicts* - ANS-*Cultural conflicts* between nurses and patients from diverse
backgrounds are related to *different time and relationship perceptions*. For example, in some
cultures, the past may influence health practices. When making decisions about health, patients
may rely on relationships with others, and their behavior may depend on the opinion of others.
\*Culture* has which four characteristics? - ANS-*Culture* has the following four characteristics:
(1) it is *learned* from birth through language acquisition and socialization.
(2) it is *shared* by all members of the same cultural group.
(3) it is *adapted* to specific conditions related to environmental and technical factors.
(4) it is *dynamic* and ever changing.
\*Diagnostic reasoning* - ANS-*Diagnostic reasoning* is the process of analyzing health data
and drawing conclusions to identify diagnoses.
\*Each person responds differently* to the same stimuli, regardless of the primary culture and
value system. You should *guard against stereotyping* individuals. You should also understand
*culture-bound syndromes,* which may have no equivalent from a biomedical perspective. -
ANS-...
\*Ethnicity* - ANS-*Ethnicity* pertains to membership in a social *group that claims to possess a
common* geographic origin, migratory status, religion, race, language, shared values, traditions
or symbols, and food preferences. One's cultural background is a fundamental component of
one's ethnic background.
\*Explanation* - ANS-*Explanation.* With these statements, you inform the person. You share
factual and objective information. This may be for orientation to the agency setting: "Your dinner
comes at 5:30 PM." Or, it may be to explain cause: "The reason you cannot eat or drink before
your blood test is that the food will change the test results."
\*Facilitation* - ANS-*Facilitation* These responses encourage the patient to say more, to
continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called general leads, these
responses show the person you are interested and will listen further. Simply maintaining eye
contact, shifting forward in your seat with increased attention, nodding "Yes," or using your hand
to gesture, "Yes, go on, I'm with you," encourage the person to continue talking.
\*First-level priority problems* - ANS-*First-level priority problems* are emergent,
life-threatening, and immediate, such as establishing an airway or supporting breathing.
\*Internal factors* - ANS-*Internal factors* are what *you* bring to the interview.
\*Interpretation* - ANS-*Interpretation.* This statement is not based on direct observation as
with confrontation, but it is based on your inference or conclusion. It links events, makes
associations, or implies cause: "It seems that every time you feel the stomach pain, you have
had some kind of stress in your life." Interpretation also ascribes feelings and helps the person
understand his or her own feelings in relation to the verbal message.
\*Nonverbal communications convey messages* from the sender to the receiver. Work to
develop the ability to read patients' nonverbal behaviors and to monitor your own nonverbal
communication. - ANS-...
\*Nonverbal modes of communication* - ANS-*Nonverbal modes of communication* include:
- Physical appearance,
, - Posture,
- Gestures,
- Facial expression,
- Eye contact,
- Voice, and
- Touch.
\*Objective data* - ANS-*Objective data* include information obtained by the health care
provider through physical assessment, the patient's record, and laboratory studies.
\*PQRSTU* - ANS-*PQRSTU* stands for *P*rovocative or palliative, *Q*uality or quantity,
*R*egion or radiation, *S*everity scale, *T*iming, and *U*nderstanding the patient's perception
of the problem.
\*Reflection* - ANS-*Reflection.* This response echoes the patient's words. Reflection is
repeating part of what the person has just said.
\*Religion* - ANS-*Religion* is the belief in a divine or superhuman power or powers to be
obeyed and worshipped as the creator or ruler of the universe.
\*Second-level priority problems* - ANS-*Second-level priority problems* are next in urgency.
They require prompt intervention to prevent deterioration, and may include a mental status
change or acute pain.
\*Silence* - ANS-Silence is golden after open-ended questions. Your silent attentiveness
communicates that the patient has time to think, to organize what he or she wishes to say
without interruption from you.
\*Socialization* - ANS-*Socialization* is the process of being raised within a culture and
acquiring the characteristics of the group. Education is a form of socialization.
\*Spirituality* - ANS-*Spirituality* is borne out of each person's unique life experience and his or
her personal effort to find purpose and meaning in life. Spirituality may be used to *find meaning
and purpose for illnesses.*
\*Subjective data* - ANS-*Subjective data* consist of information provided by the affected
individual.
\*The database* - ANS-The *database* is the totality of information available about the patient.
The purpose of assessment is to make a judgment or diagnosis.
\*Third-level priority problems* - ANS-*Third-level priority problems* are important to the
patient's health, but can be addressed after more urgent problems. Examples include lack of
knowledge or family coping.
\A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
B) used for a limited or short-term problem usually consisting of one problem, one cue complex,
or one body system.
C) used to evaluate cause and etiology of disease.
D) used to perform a thorough or comprehensive health history and physical examination. -
ANS-A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
Feedback: INCORRECT
