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NSG-121 HEALTH ASSESSMENT EXAM I STUDY GUIDE | 100% CORRECT| GRADED A

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NSG-121 HEALTH ASSESSMENT EXAM I STUDY GUIDE | 100% CORRECT| GRADED A

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How should not have a rectal temperature?


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No cardiac clients, elderly patients, can stimulate the vagus nerve and
cause bradycardia. Vagus nerve system controls specific body functions
such as your digestion, heart rate and immune system. These functions are
involuntary, meaning you can't consciously control them.

,How do you respond to a client who tells you to they don't believe in doctors'
diagnoses?


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Perception) Sounds like you are not understanding or believing what the
doctor told you.




During percussion assessment the nurse hears a dull sound in right upper quadrant.
What organ is the nurse assessing?


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Liver




Changes of Subject


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You may be tempted to change the subject when a situation is
uncomfortable for you because of your personal experiences or coping
mechanisms. For example, if you recently experienced the death of a
parent, it may be challenging at this time for you to talk with a family about
a patient who has terminal cancer. Avoiding the subject is not therapeutic
for the patient; you need to recognize that you are using coping
mechanisms to protect yourself from emotional distress. One strategy is to
seek support from others. An alternate approach is to be honest with the
patient about your situation. If emotional control is too difficult, you may
refer the patient to another nurse.

,Distractions


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in the environment contribute to nontherapeutic communication. Hectic
and rushed work environments abound across health care settings. This
contributes to patient complaints about depersonalized care. Distractions
come from various sources, such as equipment, other patients, colleagues,
pagers, and cell phones. When equipment poses a potential source of
distraction, tell the patient, silence the alarm, and resolve the problem
before conversation. An equipment alarm indicates an immediate problem
that usually takes priority over therapeutic communication.




Hand Hygiene


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The single most important action to prevent an infection




What type of patient would you do a focus assessment on?


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Patient that has a specific problem.




What is the reason for documentation?


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, Because it is a legal document. Prompt reporting and accurate recording
of patient assessment data are essential to ensure safe and efficient
delivery of care. Almost three-fourths of all serious, often life-threatening,
errors in health care (sentinel events) reported to The Joint Commission
involve failures in communication as the root cause.




head-to-toe assessment (Over all body)


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is the most organized system for gathering comprehensive physical data.
Because data in one functional area are collected from different parts of
the body, it is very inefficient to collect physical data by functional status.
For example, peripheral circulation is assessed in both the arms and the
legs.




accuracy


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Assessment information that you enter into the patient's record must
accurately reflect what you observe, hear, auscultate, palpate, or percuss.
Document subjective data using the patient's exact words whenever
possible. Your descriptions should be as precise as possible. For example,
you document the size of a wound as "6 cm by 9 cm with a 1-cm depth"
rather than as "large." Accuracy permits comparison of current findings
with future data to detect changes in patient status.




Communication Process forms:

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