BSMCON NUR 2102 - TEST 1
young children (1-6) responses to pain - ✔️✔️difficulty understanding pain but have a
basic ability to describe pain and location; everything is a "tummy ache"
school-age children - ✔️✔️better understand pain and are able to describe pain
location.
older adult responses to pain - ✔️✔️Although transmission and perception of pain may
be slowed, pain is felt no differently from that of any other adult.
lifetime of experience in coping with pain, but pain is not an expected part of aging.
How often do we assess pain - ✔️✔️On admission and every shift at minimum
Change in status
Within 30 min of parental (IV, injection) medication
Within 1 hour of oral medication
Every office visit (annual exam or focused area)
nonpharmacologic pain measures - ✔️✔️Distraction
Humor
Music
Imagery
Relaxation
Hypnosis
Biofeedback
Therapeutic touch
Cutaneous Stimulation
(TENS (transcutaneous nerve stimulation)
Acupuncture
Massage
Heat/cold therapy)
Primary prevention - ✔️✔️Addresses the needs of healthy clients to promote health
and prevent disease with specific protections; decreases the risk of exposure of an
individual or a community to disease.
Immunization programs
Child car seat education
Nutrition and fitness activities
Health ed. in schools - ✔️✔️Examples of Primary Prevention
,Secondary prevention - ✔️✔️Focuses on identifying illness, providing treatment, and
conducting activities that help prevent a worsening health status.
Communicable disease screening and case finding
Early detection and treatment of diabetes mellitus
Exercise programs for older, frail adults - ✔️✔️Examples of Secondary Prevention
Tertiary prevention - ✔️✔️Aims to prevent the long-term consequences of a chronic
illness or disability and to support optimal functioning.
Begins after an injury or illness
Prevention of pressure ulcers after spinal cord injury
Promoting independence after traumatic brain injury
Referrals to support groups
Rehab center - ✔️✔️Examples of Tertiary Prevention
Improve health priorities
Improve awareness and understanding of the progress involving health, disease, and
disability
Apply measurable health goals at the local, state, and national level
Apply best practice to strengthen policies and improve health practice
Identify the need for research, evaluation, and date collection of health disparities -
✔️✔️Healthy People 2020 Objectives to promote health and prevent disease among
the national population; updated every 10 years
Biographical Data - ✔️✔️Name, Gender, Address, phone number, email address, birth
date, birthplace, race/ethnicity, religion, marital status, occupation, contact person, and
source of data
Reason for Seeking Health Care - ✔️✔️Chief complaint (CC) or presenting problem
History of Present illness - ✔️✔️Conduct a symptom analysis - include OLDCARTS
Present Health Status - ✔️✔️Focus on patient condition's (acute and chronic),
medications the patient is currently taking, and allergies the patient has experienced.
Past Health History - ✔️✔️Explore past and present conditions that may have some
effect on patient's current health needs and problems.
Family History - ✔️✔️Review of patient's blood relatives (biologic), spouse and children
to identify illnesses of genetic, familial or environmental nature that may affect the
patient's current or future health.
, Personal and Psychosocial History - ✔️✔️Explores a variety of topics, including any
information that affects the patient's physical and mental health.
Review of Systems - ✔️✔️Conducted to inquire about past & present health of each of
the patient's body systems. Use OLDCARTS. If sufficient data has been collected about
the body system in the Present Illness/Present Health status section, these questions
are not repeated.
No delegation to NAP.
The RN is not only responsible for gathering data, but clustering it and using it in
decision making.
The delegating nurse retains responsibility and accountability for nursing care of the
client, including nursing assessment, planning, evaluation, documentation, and
supervision. The delegating nurse shall assess the clinical status and stability of the
client's condition; determine the type, complexity, and frequency of the nursing care
needed; and delegate only those tasks that:
a. Do not require the exercise of independent nursing judgment;
b. Do not require complex observations or critical decisions with respect to the nursing
task or procedure;
c. Frequently recur in the routine care of the client or group of clients;
d. Do not require repeated performance of nursing assessments;
e. Utilize a standard procedure in which the tasks or procedures can be performed
according to exact, unc - ✔️✔️According to the ANA Standards of Practice, what is the
registered nurse's role in assessment?
Primary prevention - ✔️✔️Prevent disease from developing through healthy lifestyle
Secondary prevention - ✔️✔️Screening efforts to promote the detection of disease to
halt the progression the disease process
Tertiary prevention - ✔️✔️Minimizing the disability from acute or chronic disease or
injury
Help the client maximize his or her health
Health promotion - ✔️✔️Behavior motivated by the desire to increase well-being and
actualize human health potential
Health protection - ✔️✔️Behavior motivated by a desire to actively avoid illness, detect
it early, or maintain functioning within the constraints of illness
Clinical prevention - ✔️✔️Individually focused interventions such as immunization,
screenings, and counseling, aimed at preventing escalation of diseases and conditions
young children (1-6) responses to pain - ✔️✔️difficulty understanding pain but have a
basic ability to describe pain and location; everything is a "tummy ache"
school-age children - ✔️✔️better understand pain and are able to describe pain
location.
older adult responses to pain - ✔️✔️Although transmission and perception of pain may
be slowed, pain is felt no differently from that of any other adult.
lifetime of experience in coping with pain, but pain is not an expected part of aging.
How often do we assess pain - ✔️✔️On admission and every shift at minimum
Change in status
Within 30 min of parental (IV, injection) medication
Within 1 hour of oral medication
Every office visit (annual exam or focused area)
nonpharmacologic pain measures - ✔️✔️Distraction
Humor
Music
Imagery
Relaxation
Hypnosis
Biofeedback
Therapeutic touch
Cutaneous Stimulation
(TENS (transcutaneous nerve stimulation)
Acupuncture
Massage
Heat/cold therapy)
Primary prevention - ✔️✔️Addresses the needs of healthy clients to promote health
and prevent disease with specific protections; decreases the risk of exposure of an
individual or a community to disease.
Immunization programs
Child car seat education
Nutrition and fitness activities
Health ed. in schools - ✔️✔️Examples of Primary Prevention
,Secondary prevention - ✔️✔️Focuses on identifying illness, providing treatment, and
conducting activities that help prevent a worsening health status.
Communicable disease screening and case finding
Early detection and treatment of diabetes mellitus
Exercise programs for older, frail adults - ✔️✔️Examples of Secondary Prevention
Tertiary prevention - ✔️✔️Aims to prevent the long-term consequences of a chronic
illness or disability and to support optimal functioning.
Begins after an injury or illness
Prevention of pressure ulcers after spinal cord injury
Promoting independence after traumatic brain injury
Referrals to support groups
Rehab center - ✔️✔️Examples of Tertiary Prevention
Improve health priorities
Improve awareness and understanding of the progress involving health, disease, and
disability
Apply measurable health goals at the local, state, and national level
Apply best practice to strengthen policies and improve health practice
Identify the need for research, evaluation, and date collection of health disparities -
✔️✔️Healthy People 2020 Objectives to promote health and prevent disease among
the national population; updated every 10 years
Biographical Data - ✔️✔️Name, Gender, Address, phone number, email address, birth
date, birthplace, race/ethnicity, religion, marital status, occupation, contact person, and
source of data
Reason for Seeking Health Care - ✔️✔️Chief complaint (CC) or presenting problem
History of Present illness - ✔️✔️Conduct a symptom analysis - include OLDCARTS
Present Health Status - ✔️✔️Focus on patient condition's (acute and chronic),
medications the patient is currently taking, and allergies the patient has experienced.
Past Health History - ✔️✔️Explore past and present conditions that may have some
effect on patient's current health needs and problems.
Family History - ✔️✔️Review of patient's blood relatives (biologic), spouse and children
to identify illnesses of genetic, familial or environmental nature that may affect the
patient's current or future health.
, Personal and Psychosocial History - ✔️✔️Explores a variety of topics, including any
information that affects the patient's physical and mental health.
Review of Systems - ✔️✔️Conducted to inquire about past & present health of each of
the patient's body systems. Use OLDCARTS. If sufficient data has been collected about
the body system in the Present Illness/Present Health status section, these questions
are not repeated.
No delegation to NAP.
The RN is not only responsible for gathering data, but clustering it and using it in
decision making.
The delegating nurse retains responsibility and accountability for nursing care of the
client, including nursing assessment, planning, evaluation, documentation, and
supervision. The delegating nurse shall assess the clinical status and stability of the
client's condition; determine the type, complexity, and frequency of the nursing care
needed; and delegate only those tasks that:
a. Do not require the exercise of independent nursing judgment;
b. Do not require complex observations or critical decisions with respect to the nursing
task or procedure;
c. Frequently recur in the routine care of the client or group of clients;
d. Do not require repeated performance of nursing assessments;
e. Utilize a standard procedure in which the tasks or procedures can be performed
according to exact, unc - ✔️✔️According to the ANA Standards of Practice, what is the
registered nurse's role in assessment?
Primary prevention - ✔️✔️Prevent disease from developing through healthy lifestyle
Secondary prevention - ✔️✔️Screening efforts to promote the detection of disease to
halt the progression the disease process
Tertiary prevention - ✔️✔️Minimizing the disability from acute or chronic disease or
injury
Help the client maximize his or her health
Health promotion - ✔️✔️Behavior motivated by the desire to increase well-being and
actualize human health potential
Health protection - ✔️✔️Behavior motivated by a desire to actively avoid illness, detect
it early, or maintain functioning within the constraints of illness
Clinical prevention - ✔️✔️Individually focused interventions such as immunization,
screenings, and counseling, aimed at preventing escalation of diseases and conditions
