Nurs 251 Final Exam PSU questions with correct answers

Components of Health History Biographic data, reason for seeking care, history of present illness, past medical history, family history, review of systems, functional assessment or activities of daily living Subjective Data things a person tells you about that you cannot observe through your senses; symptoms Objective Data information that is seen, heard, felt, or smelled by an observer; signs Types of Health History Focused, episodic/emergent, Complete Complete Health History Total history and full physical examination Current and past health state Episodic/Emergent Health History Urgent, rapid collection of information with life saving measurements Focused Health History Targeted, limited to 1 body system Types of therapeutic communication Facilitation, Silence, Reflection, Clarification, Confrontation, Interpretation Facilitation encourages patients to say more ex: mhm, go on Silence Directed attentiveness, allows patient to think Reflection Echoes to help express meaning Clarification useful when patients words are confusing Confrontation clarifying inconsistent information Interpretation making connections to identify cause or conclusion Biographic Data name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language Reason for seeking care Brief, spontaneous statement in the person's own words that describes the reason for the visit History of Present Illness (HPI) information gathered regarding the symptoms and nature of the patient's current concern Past Medical History Diagnosis, past illnesses Review of Systems (ROS) inquires about the system directly related to the problems identified in the history of the present illness Use of subjective data, not what you see Functional Assessment A type of behavioral assessment used to determine functional relations between challenging behavior and environmental events Temperature normal 35.8 C to 37.3 C (96.4 to 99.1 F) Blood Pressure 120/80 mmHg Respirations 10-20 bpm First-level priority Emergent, life threatening, immediate Ex: Airway Second-level priority Requiring attention to avoid further deterioration Ex: severe pain post surgery Third-level priority Important to patients health but can be addressed at a later time Ex: diabetic teaching before discharge Pain Assessment Provocative or Palliative (what makes it worse/better) Quality or Quantity (For example, is the pain sharp or dull, throbbing?) Regian or Radiation(Location) Severity Scale (Numeric pain intensity scale) Timing (Onset) COLDSPA Character, Onset, Location, Duration, Severity, Pattern, Associated Factors / How it Affects the client Pulses pressure wave created by each heartbeat Bradycardia: less than 60 bpm Tachycardia: more than 100 bpm Amplitude of pulses 3+ = large or bounding 2+ = normal or average 1 = small or reduced 0 = absence of pulse Pulse deficit difference between the apical and radial pulse rates Pulse pressure difference between systolic and diastolic pressure CN I Olfactory; smell; sensory CN II Optic: Sensory: Vision Sneal Eye Chart test visual acuity and fields by confrontation CN III Oculomotor: Both: Motor- extraocular muscle movement; Parasympathetic- pupil constriction PERRLA CN IV Trochlear; Motor; Down and inward movement of eye CN V Trigeminal: Both: Motor- muscles of mastication; Sensory- face sensation Face touch and clench jaw CN VI Abducens: Motor: Lateral movement of eye CN VII Facial: Both: Motor- facial muscles; Sensory- Taste Smile, frown, puff cheeks CN VIII Acoustic: Sensory: Hearing and equilibrium whisper test CN IX Glossopharyngeal; Motor: pharynx talking and swallowing, gag reflex; Sensory: Taste & senses carotid blood pressure CN X Vagus - senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste, talking swallowing Ahhhh, swallow CN XI Spinal Accessory: Motor: Movement of trapezius sternomastoid muscles shrug shoulders and turn head CN XII Hypoglossal: Motor: Tongue movement stick out tongue glascow coma scale highest 15, lowest 3 Cerebellum Balance and coordination, muscle tone of voluntary movements RAM Rapid altering movement test Cerebellar Test Nose-Finger-Nose Gait and balance tests Tandem walking Romberg sign DTR point scale 4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response 3 types of reflexes Stretch on/ Deep tendon (myotatic) ex: knee jerk Superficial (cutaneous) ex: plantar reflex Visceral (organ) ex: pupil response Accommodation adaptation of the eye for near vision by increasing the curvature of the lens movement of ciliary muscles: convergence (motion towards axes of eyeballs) pupils constrict when adapting for near vision (im going to go towards your nose but wont touch it) Confrontation Test Test Peripheral Vision Position yourself at eye level with the person, about 2 feet away. Direct the person to cover one eye with a card, and with the other eye to look straight at you. Cover your own eye opposite to the person's covered one. You are testing the uncovered eye. Hold a pencil or your flicking finger as a target midline between you and slowly advance it in from the periphery in several directions. extraocular movement use six cardinal positions of gaze to see if there is EOM present